1
Q
Brief history of PTSD
A
- goes back a long way
- account of PTSD or similar sorts of symptoms have been documented for a very long time
- fills an important gap in psychiatry
- this is because its cause was the result of an event that the individual suffered / witnessed rather than a personal weakness
2
Q
PTSD symptoms/conditions over time:
Soldiers Heart
A
- suggested that a physical injury was the cause of the symptoms
- marked by a rapid pulse, anxiety and trouble breathing
3
Q
PTSD symptoms/conditions over time:
Da Costa’s Syndrome
A
- US doctor Jacob Mendez Da Costa
- studied civil war soldiers with ‘cardiac’ symptoms
- described it as overstimulation of the heart’s nervous system or Da Costa’s
- soldiers were often to returned to battle after receiving drugs to control symptoms
4
Q
PTSD symptoms/conditions over time:
Railway Spine
A
- European reports of the symptoms
- rail travel became more common as did railway accidents
- autopsies of injured passengers
- suggested injury to the central nervous system
- symptoms associated with traumatic experiences - PTSD?
5
Q
PTSD symptoms/conditions over time:
Shell Shock
A
- symptoms of present day PTSD - a reaction to the explosion of artillery shells?
- included panic, sleep problems etc
- first thought - the result of hidden damage to the brain caused by the impact of big guns
- very varied treatment during WW1 - few days of rest before returning to war
- Myers - looked at it as a disorder
- argued that it could be cured through cognitive & affective reintegration
- felt that he could help by reviving and integrating the individual’s memory within his consciousness
6
Q
PTSD symptoms/conditions over time:
Combat Stress Reaction / Battle Fatigue
A
- replaced the shell shock diagnosis in WW2
- soldiers became battle weary and exhausted
- lots of officers in the military did not believe that the disorder was real
- lots of military discharges in WW2 were a result of combat exhaustion
7
Q
PTSD symptoms/conditions over time:
Vietnam
A
- delayed stress
- turning point for PTSD
- bought it to the forefront of research
- lots of campaigning to bring the disorder into the public and medical eye
8
Q
PTSD - military?
A
- not a disorder confined to the military
- BUT a lot of research has been done - due to the opportunities to study it maybe?
- Veterans associations have been pushing for getting research done
- military does fund a lot of research
9
Q
PTSD - causes?
A
- caused by some sort of traumatic experience
- some occupations are likely to see more horrific scenes; police, rescue services, military personnel
- formerly thought of as an anxiety disorder that develops after experiencing or witnessing a life threatening event
- can be violent assault, accidents, war or sometimes severe emotional loss
- now in a new category - ‘Trauma and Stress Related Disorders’
10
Q
PTSD - prevalence and co-morbidity?
A
High numbers in the US, bit less in the UK
- due to the motivations after Vietnam?
7.7% in USA (NIH, 2005)
3% in UK - Adult Psychiatric Morbidity Study
High co-morbidity with other disorders
- depression, anxiety, substance abuse
About 70% of those who suffer do not seek any help
11
Q
DSM-V Criteria for PTSD
A
- Trauma or stressor - related disorder
- Numerous criteria
- Experience of the event
- Cues that make you remember
- Avoidance of anything associated with the event itself
- Negative change in mood and emotions
- Arousal and reactivity are affected
- Distortion of the event - self blame can result as well as detachment from life
- have to have been going on for a month!
12
Q
NICE
A
National Institute of Health and Care Excellence
- provides national guidance and advice to improve health and social care
- doesn’t license drugs but does make recommendations
- based on the ICD-10
13
Q
NICE symptoms for PTSD
A
> re-experiecneing symptoms - this can include flashbacks, nightmares, intrusions
> avoiding things that remind the person of the traumatic event - try to avoid think about or remembering the event
> hyper-arousal - hyper-vigilence, heightened startle response, sleep problems
> emotional numbing - difficulty with feelings, detachment
> mostly happens straight away but for some there is a delayed onset or the sufferers do not seek help until much later
> can be co-morbid - e.g. depression, anxiety disorders, substance abuse
14
Q
Mnemonic - Lange, 2000
A
DREAMS
D - detachment
R - re-experiencing event
E - event had emotional events
A - avoidance
M - month in duration (symptoms more than one month)
S - sympathetic hyperactivity or hyper-vigilence
15
Q
NICE - Assessment
A
- initial assessment and coordination of care - GPs
- includes determining the need for emergency medical or psychiatric assessment
- has to be comprehensive - physical, psychological, a social needs and a risk assessment
- P preference for treatment choice - important! - should be given sufficient information about the nature of treatments
- monitoring - needs to be clear agreement amongst health professionals about the responsibility for monitoring those with PTSD
- family support - play a central role in supporting P’s
- BUT depending on the nature of the trauma and consequences, many families may also need support for themselves (be aware of the impact all around!)
- self-help groups - should inform families and carers should be informed of these
Practical and social support can play an important part in facilitating a P’s recovery from PTSD, particularly immediately after the trauma
16
Q
What can we use to diagnose PTSD?
A
Screening tools - only says it is likely that the disorder is present
Trauma / Symptom Severity - scales that might identify these include the Davidson Trauma Scale and DAPS (detailed assessment of post-traumatic stress)
Structured / Semi-structed interviews:
- CAPS - Clinician Administered PTD Scale
- CIDI - Composite International Diagnostic Interview
- DIS-1V - Diagnostic Interview Schedule for DSM 1V
–> for interviews, expertise is paramount!
17
Q
CAPS - Clinician Administered PTD Scale
A
- gold standard in PTSD assessment
- 30 item structured interview
- can be used to make current diagnosis, lifetime diagnosis and assess symptoms over the past week
- some questions assess severity of the disorder
- can’t assess for co-morbidity though
18
Q
CIDI - Composite International Diagnostic Interview
A
- comprehensive, fully-structured interview designed to be used by trained interviewers
- used for the assessment of mental disorders according to the definitions and criteria of ICD-10 and DSM-IV
- intended use - epidemiological and cross-cultural studies as well as clinical and research purposes
- lets the investigator measure the prevalence, severity and determine the burden, assess service use, use of medications in treatment, assess who is treated, untreated and barriers to treatment
- doesn’t require a trained clinician
- very specific
19
Q
DIS-IV - Diagnostic Interview Schedule for DSM-IV
A
- fully structured questionnaire designed to ascertain the presence of absence of major psychiatric disorders outlined in the DSM-IV
- attempts to mimic a clinical interview by using questions to determine whether psychiatric symptoms endorsed by a respondent are clinically significant and are not explained by medical conditions or substance abuse
- has to be administered by trained interviewers
- used a lot in research
20
Q
What are the different perspectives explaining PTSD?
A
Medical Model Dimensional Model Cognitive Model Behavioural Model Spiritual Model Narrative Model Systems Approach
21
Q
Jakovlijević et al (2012)
A
Lots of different models / perspectives of PTSD
Psychotraumatisation - continues to be a pervasive aspect of life in the 21st century all over the world
PTSD and other trauma related disorders are highly prevalent and disabling as well as being a source of huge suffering
Multi-interpretable approach
- can be explained from various, but mutually complementary, theoretical and conceptual perspectives
- different internal logics but all plausible interpretations
22
Q
Medical Model - disease/illness perspective
- Jakovlijević et al (2012)
A
Same as how somatic medicine works - something fundamentally different from normal function
- illness - damage to structure / function of the brain
- can be prevented or cured
- linking symptoms to specific patho-physiological processes involved and then prescribing specific treatments
> specific structural and functional changes have been reported in the brains of P’s with PTSD
23
Q
Medical Model - in terms of psychodynamic psychiatry
- Jakovlijević et al (2012)
A
Illness is subjective and is an interpersonal manifestation, to do with meaning
- problem of the whole person therefore is subjectively defined
- reflects the malfunction of a harm avoidance mechanism
- normally use past experiences to escape actual or future dangers, hazards and damage
Treatment - attention to the WHOLE person
- assumption that disease captures the essence of illness if erroneous
- in clinical practise, PTSD modifies both as illness and disease!
24
Q
Medical Model - in terms of social psychiatry
Jakovlijević et al (2012)
A
PTSD - a sickness that represents community and health authority attitude
- influence of society - shape how P’s feel about the disorder
- political valence - influences the construct of the disorder and the response to P’s with the disorder
25
Jakovlijević et al (2012) - an explanation in terms of medical factors?
Traumatic situations - neurons can literally be 'excited to death' - this results in organic brain changes
Fundamental problem in PTSD - a fixation on trauma and damage of the self-regulatory systems which are unable to distinguish relevant from irrelevant stimuli and to restore to the organism to its pre-trauma state
26
Dimensional Model
| - Jakovlijević et al (2012)
Shift to the appreciation of meaning in human behaviour, personhood and personality assessment in health and illness
- realting to what or who someone is to their personality with vulnerability and resilience and specific way of being in the world
- vulnerability-stress / stress-diathesis model
- some P's are more vulnerable to stress / mental distress
Treatment - focus on helping P's use their personality resources and strengths to increase their well-being and restore resilience SO that they can cope with stress more successfully
27
Dimensional Model - cause of PTSD
| - Jakovlijević et al (2012)
May be related to the way in which individuals interpret the meaning of an event
Distinguishing between a potentially traumatic event from an individual's reaction --> very important!
28
Dimensional Model - factors
| - Jakovlijević et al (2012)
After traumatic stress, PTSD appears from a complex interaction of three groups of factors
(1) 'risk' or 'vulnerability' factors
- enhance the likelihood of PTSD
(2) 'protective' factors
- enhance the likelihood of recovery from trauma and stress
(3) 'generative' or 'creative' factors
- increase revelatory learning, resource acquisition and development, accentuating personal growth
29
Dimensional Model - what may PTSD be derived from?
| - Jakovlijević et al (2012)
Personal dispositions (diathesis) and stressful life circumstances (stress-diathesis model)
Personality weakness (vulnerability), risky traits and low resilience have been shown to account directly for PTSD patterns
30
Dimensional Model - resilience
| - Jakovlijević et al (2012)
Can be defined as the ability to recover quickly from change, threats, trauma, misfortune, tragedy or illness
- facility of the body and mind to regenerate and resist when faced with disorder, illness, disease or disruption
- ALSO requires a beneficent relationship between the traumatised individual and the larger social and physical environment
31
Cognitive Model
| - Jakovlijević et al (2012)
Focuses on what someone is thinking about, perceives and learns about or assess as valuable - i.e. which ideas and values in life should be followed
32
Behavioural Model
| - Jakovlijević et al (2012)
PTSD:
- fundamentally a disorder of reactivity which manifests itself as characteristic maladaptive behaviour during interactions with the interpersonal or physical environment
33
Cognitive Model - how is it explained
| - Jakovlijević et al (2012)
- pathological behaviour leading to PTSD is associated with dysfunctional and conflicting cognitive strategies, misinterpretations and misrepresentations
- proximal cause - how P's interpret the meaning of what happens and how they explain it
- much of PTSD - may be created by errors or biases in thinking, e.g. catastrophic thinking
- negative cognitive styles with a deficit for retrieval of positive memories contributes to PTSD development and severity
- when these negative thoughts are corrected, health can be established again
34
Behavioural Model - how it is explained
| - Jakovlijević et al (2012)
- explained by classic fear conditioning
- the traumatic (unconditioned) stimulus automatically evokes the post-traumatic (unconditioned) emotional response (fear, helplessness and/or horror) and/or dissociation
- conditioned stimuli which are reminders of the experienced traumatic event evoke similar conditioned emotional responses, dissociation and flash-backs as well as fear-induced avoidance and protective behaviours
--> trauma-focussed CBT with emotion-regulation training sessions show significant effectiveness
35
Spiritual / Transcendental Perspective
| - Jakovlijević et al (2012)
- being talked about more
- don't know too much about the relationship as spiritually has long been a taboo issue in mental health care practises
- spiritual alienation and loss of sense have been frequently reported in PTSD P's - difficulties in reconciling religious beliefs with traumatic events
- spiritually - personal experience with many different definitions
- spiritual beliefs are of great importance to many P's and may have a significant impact on traumatic life events and PTSD
36
Spiritual / Transcendental Perspective - effects of trauma
| - Jakovlijević et al (2012)
Trauma can have positive and negative effects on spiritual experiences, beliefs etc
Positive effects:
- appreciation of life, enhanced spiritual well-being etc
Negative effects:
- can be associated with spiritual struggles
37
Narrative Perspective - background
| - Jakovlijević et al (2012)
Based on the logic of narrative, narrative self and distressed states of the should, which are quite natural, understandable and the result of adverse impressions and experiences
- our identity is shaped by narratives or stories
- both are uniquely personal and culturally general
- we give meaning to our lives and the world by the stories we tell ourselves and each other ---> hence we define our experiences, actions and destiny
38
Narrative Perspective - PTSD
| - Jakovlijević et al (2012)
PTSD - often points to a tragic story 'dread frozen in memory', existential despair and life irony
- focuses on the life story of a P with PTSD and provides a better understanding not only of the P's actual mental state but also of the significance, meaning and processes contributing to the onset and maintenances of clinical symptoms
- life experiences, organisation of personality and psychological life script -> needed to understand the individual psychopathology
- from a narrative viewpoint, PTSD may be related to the P's specific sad and defeating life story, destructive self-attitude and a particular unconscious loser life-script
39
Systems Perspective - background
| - Jakovlijević et al (2012)
According to this theory, the genome operates within the context of the cell, the cell within the context of the body, the body within the context of the self, the self within the context of the universe
40
Systems Perspective -
| - Jakovlijević et al (2012)
- mental disorders and somatic diseases/illnesses can be conceptualised within different body, energy, mental, family, social and etc systems
- PTSD may reflect the problems in many different, more or less related systems therefore there are many roads to PTSD consideration and understanding
- individual and personal condition as well as a family condition and a social condition
41
Jakovlijević et al (2012) - conclusion
- human response to traumatic stress - one of the most important public health issues in modern medicine and psychiatry
- traumatic stressful events and the subsequent way in which individuals and groups deal with them play a crucial role in the development of PTSD as well as many other disorder
- PTSD - comprises a complex set of multi-dimensional domains
- so it seems improbable that any single perspective will be sufficient to provide a comprehensive understanding and treatment of this disorder
42
Medical Model - Psychophysical Measures
- HR, skin conductance, EMG, ERP etc
| - startle responses - those with PTSD are far more likely to be startled
43
Medical Model - Psychophysical Measures
| - Pole (2007)
Meta-analysis of the psychophysiology of PTSD
- various psychophysiological measures examined
- EMG, HR, skin conductance (SC) and blood pressure
Significant weighted mean effects of PTSD were observed for:
- HR and SC in resting baseline studies; eye-blink EMG and SC habituation slope in startle studies; HR in standardised trauma cue studies
Most robust correlates of PTSD were SC habituation slope, facial EMG during idiographic trauma cues and HR during all study types
Overall, the results support the view that PTSD is associated with elevated psychophysiology
PROBLEM - limited research base
- focus on M veterans and neglect of potential PTSD symptoms!
44
Medical Model - Psychophysical Measures
| - Tan et al (2011)
Heart Rate Variability and PTSD - pilot study
- some treatments - not universally effective as some O's continue to struggle with symptoms
- HRV - indicator of autonomic nervous system function
- comparing HRV's of combat-PTSD veterans with controls before and after an intervention
- intervention = HRV biofeedback
Biofeedback group - CAPs score deuced 18% vs TAU controls of 9%
- reduction of symptoms - noticeable by the P!
Good follow-ups immediately after and 6 months after
"This treatment has helped me teach myself how to control my own PTSD symptoms"
- given P's some control over their behaviour
- make them feel as if they are in charge - helps recovery?
- give them some control - sense of empowerment?
- beneficial to treatment outcome?
45
Medical Model - Psychophysical Measures
| - Tan et al (2011) - after thoughts?
Preliminary results - if replicated, would constitute a fairly meaningful reduction in PTSD symptoms?
PTSD veterans - significantly depressed HRV compared to those without PTSD
- shows that this HRV biofeedback was both feasible and acceptable to the veterans for their symptoms
- consistent with other research indicating that HRV biofeedback training provides a reduction in psychiatric symptoms associated with trauma
PTSD symptoms - associated / include hyper-arousal
- therefore, seems like a good treatment option to be honest
- only a pilot study!
- promising results and is consistent with previous research findings
46
Medical Model - Neuroimaging
Wang et al (2010)
- lower volume of hippocampus
Sekiguchi et al (2013)
- lower volume of PFC
47
Medical Model - Neuroimaging
| - Hughes and Shin (2011)
Functional neuroimaging studies of PTSD
- methods used - fMRI, SPECT and PET
- all thought to be approximate indices of relative regional activity in the brain
P's often presented with emotional stimuli
Brain areas looked at:
- amygdala, medial prefrontal cortex, hippocampus, insula
48
Medical Model - Neuroimaging
| - Hughes and Shin (2011) - AMYGDALA
Main findings - increased amygdala responsively in PTSD
- shown with script-driven imagery, exposing to combat sounds vs white noise in combat veterans, trauma related vs unrelated words in a PTSD group
- increased activation here has also been found in trauma-unrelated stimuli
- e.g. fearful facial expression vs happy expression
(increased activation for fearful expressions)
Also found for neutral stimuli also
- Semple et al - greater amygdala blood flow in combat veterans with PTSD and co-morbid substance abuse vs healthy controls
- neutral auditory continuous performance task during PET scanning
- responsivity - correlates positively with PTSD symptoms severity
49
Medical Model - Neuroimaging
| - Hughes and Shin (2011) - MEDIAL PREFRONTAL CORTEX
- less activation here in P's with PTSD
| - less response / blood flow seen in response to trauma related stimuli
50
Medical Model - Neuroimaging
| - Hughes and Shin (2011) - HIPPOCAMPUS
- findings regarding hippocampal responsivity in PTSD have been mixed
- evidence to show decreased hippocampal activation in PTSD
- BUT there is also evidence to show increased hippocampal activation
OVERALL, seems to be that the direction of hippocampal functional abnormalities depends in part on the type of tasks and analyses employed
51
Medical Model - Neuroimaging
| - Hughes and Shin (2011) - INSULA
Several studies have reported increased activation here in PTSD
Lindauer et al
- increased activation in the R insula to trauma-related scripts in P's with PTSD compared with trauma-exposed control P's AND increased activation here too using emotional, trauma-unrelated stimuli
- exposure to painful stimuli - also has been reported to increase insula activation in PTSD
Some studies have reported a positive correlation between activation in the insula and symptom severity
52
Medical Model - Neuroimaging
| - conclusions
- functional neuroimaging studies have produced vast amount of information about the disorder
- BUT many aspects of the neurocircuitry behind it remain incompletely researched and understood
- different PTSD profiles may have different neural signatures
- eventual goals of research - use these profiles to determine what form of treatment would be the most appropriate
- another important future direction - to determine the origin of functional abnormalities
Continued research is needed to better understand the roles of the brain regions involved in the neurocircuitry of PTSD and to clarify the origin and potential clinical implications of their functional abnormalities
53
Medical Model - Hormonal
- SNS hyperactivity / cortisol levels / catecholamines
NOTE:
- lots of research is now discrediting the link between PTSD and low cortisol levels!
54
Medical Model - Genetics
Vulnerability to PTSD through personality traits?
PROBLEM:
- there is no conclusive evidence of genetic variants that either presides or protect the individual from PTSD
55
Psychological Theories - Emotional Processing
| - Foa and Kozak (1986)
- emotions - represented by information structures in memory
- anxiety occurs when an information structure that serves as program to escape or avoid danger is activated
- emotional processing - the modification of memory structures that underlie emotions
- 'fear structures' in memory - exist to deal with danger
- when we encounter trauma, our view of the world as a safe place is questioned and self efficacy may be affected
56
Psychological Theories - Emotional Processing
| - Wolf et al (2009)
Assessed 2 forms of emotional abnormality in PTSD - numbing and heightened negative emotionality
- veterans with and without PTSD rated their emotional responses to images varying in trauma-relatedness and affective qualities
- PTSD veterans responded to unpleasant images with greater negative emotionality (enhanced arousal and lower valence ratings) that those without PTSD
- this effect was modified by the trauma relatedness of the image, stronger effects being shown for trauma-related images
- numbing - needs to be assessed a bit more!
57
Psychological Theories - Dual Representation
Different types of memory - verbally accessible and situationally accessible
58
Psychological Theories - Dual Representation
| - verbally accessible
Leads to emotional reaction to trauma
| - e.g. recurrent recollections
59
Psychological Theories - Dual Representation
| - situationally accessible
Unconscious until cued
- leads to dreams and flashbacks
- recreates the emotions at the time of the trauma
60
Psychological Theories - Dual Representation
| - explain - part 1
- many features and details of some traumatic event (sound, smells, sights) are initially retained in situationally accessible memory
- when this information to reflected upon consciously (trying to understand or integrate) they become retained in verbally accessible memory
- sometimes after a traumatic event - P's try to dissociate themselves from the event
- they might attempt to distract themselves from memories of this event to preclude negative mood states
SO - most of the features / details of the event will be retained in situationally accessible memory rather than verbally accessible memory
61
Psychological Theories - Dual Representation
| - explain - part 2
- situationally accessible memory - primarily represents sensory information and spatial images
- because this information is not integrated of understood, the temporary sequence is not represented
- cues or stimuli in the environment that are associated with this traumatic event will tend to activate or prime the contents of this memory system
- P's will then experience intrusive images and flashbacks that are hallmarks of PTSD
- SO, dissociation immediately after some traumatic event should predict subsequent PTSD!
e.g. Ozer et al (2003) - showed that dissociation shortly after the traumatic event (peritraumatic dissociation) was highly related to subsequent PTSD
62
Cognitive Model - Ehler and Clark (2000)
The sufferer thinks about the event in a negative way and see the world as a dangerous, themselves as being unable to cope and therefore misinterpret situations
PTSD arises when the memory of the trauma brings about feelings of current threat due to appraising situations in a strongly negative ways
63
Summary of models of PTSD
PTSD P - hyper vigilant to trauma cues
VA-memory - emotional reaction to trauma
SA-memory - sits there and does nothing until it is cued
PFC - temporarily shuts down as stress level increases to a high level?
Cognitive - think negatively so see the world as a dangerous place
Continuing sense of threat - it has happened once before, so it can easily happen again
Data processing - perceptual priming?
Current Trends in Clinical Psychology
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